Health Care Insurance Proposal form

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Gavin Wheeler
5 years ago
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1 Health Care Insurance Proposal form Completing the Proposal form 1. This proposal must be fully complete including all the required documents 2. It is a duty of prosper to disclose all the material facts, if it would influence the judgement of a prudent insurer. 3. Insurance is based on utmost good faith and in the absence of such good faith, Solarelle may treat your policy as if it never existed if the misrepresentation or your non-compliance with your duty of disclosure was fraudulent. 4. Solarelle assure for the al or Sensitive Information/s that we collect are secured from the proposer is secured. Without such Information Solarelle may not be able to process your application, administer your policy or assess your claims. 5. Solarelle may obtain Information from government offices and third parties to assess a claim in the event of loss or damage. PROPOSER INFORMATION Name of the Proposer: Address: Postal Code: ID/Passport No: Telephone: Fax: Company Registration No: Nature of Business: Company: Nationality: Marital Status: ID Proof Type: Passport National Identity Card Driving License Other (Provide Detail) Contact Position: Mobile Number ID Proof No: Annual Income: Detail: SUBJECT MATTER Cover required: Plan: Standard Policy Period: 1 Year Exclusive Other Premium Proposed Policy Period: From: Type: Individual Floater To:

2 Proposed (s) Details #1: Weight: kg Gender: Male Female Sum : CI Sum : #2: Weight: kg Gender: Male Female Sum : CI Sum : #3: Weight: kg Gender: Male Female Sum : CI Sum : #4: Weight: kg Gender: Male Female Sum : CI Sum : #5: Weight: kg Gender: Male Female Sum : CI Sum : #6: Weight: kg Gender: Male Female Sum : CI Sum : Please paste stamp sized photograph(s) in sequence ( 1, 2 and so forth) as specified in section 3 Proposed insured(s) details **Family Floater Policy will have same Sum for all members **Designation/Exact nature of duties **Critical Illness Sum would be 50% or 100% of the Sum subject to a minimum of MVR xxxx.xx and maximum of MVR xxxxxxx.xx and the same rule is applicable to all members

3 MINEE DETAILS In the event of death of an any payment due under the Policy shall become payable to the nominee in accordance with the Policy terms and conditions. The nominee must be an immediate relative of the Prosper. Nominee for any of the persons proposed to be insured shall be the proposer. Nominee Name Relationship Address of the Nominee *If the Nominee is minor, Name and Address of Appointee and Relationship with Minor: Appointee Name Relationship Address of the Nominee EXISTING/PREVIOUS INSURANCE DETAILS Is the proposer or the persons proposed, already insured under a plan with Solarelle Insurance Private Limited or any other insurance company? Yes No If, please indicate below Policy/Application number(s), mentioning application number in case of pending proposal. Since when are you continuously insure? Do you want us to consider these details for continuity? Yes No Policy No./Application No. Insurer Period of Insurance Sum From To (MVR) Claims lodged during the preceding years *Note: Continuity of benefits shall T be considered If the above question of want of continuity is not replied affirmative, details are not provided and Portability form and relevant supporting documents are not submitted. Medical and Lifestyle Information MEDICAL AND LIFESTYLE INFORMATION Medical History: Please answer the below mentioned questions Yes or No ONLY: A) Has any of the person proposed to be insured ever suffered from/are currently suffering from any of the following? High or low blood pressure, Chest Pain, or any other cardiac disorder? 2 Tuberculosis, Asthma, Bronchitis or any other lung/respiratory disorder? 3 Ulcer(Stomach/Duodenal), Live, gall bladder disorder or any other digestive tract disorder? 4 Kidney Failure, Stone in kidney or urinary tract, Prostate disorder or any other kidney/ urinary tract disorder? 5 Stroke, Epilepsy (fits), Paralysis or any other nervous system (Brain, Spinal cord, etc) Disorder? 6 Diabetes, Impaired glucose tolerance (Prediabetes), Thyroid/Pituitary Disorder or any other endocrine disorder? 5 6

4 7 Tumor (Swelling)-benign or malignant, any external ulcer/growth/cyst/mass anywhere in the body? 8 Arthritis, Spondylosis or any other disorder of the muscle/bone/joint? 9 Diseases of the Ear/Nose/Throat/Teeth/ Eye (please mention Dioptres in case of refractory error)? 10 HIV/AIDS or sexually transmitted diseases or any immune system disorder? 11 Anaemia, Leukaemia, Lymphoma or any other blood/lymphatic system disorder? 12 Psychiatric/Mental illnesses or Sleep disorder? 13 Uterine Fibroid, Fibroadenoma breast or any other Gynaecological (Female reproductive system)/breast disorder? B) Has any of the persons proposed to be insured; 14 Been addicted to alcohol, narcotics, habit forming drugs or been under detoxication therapy? 15 Been under any regular medication (self/ prescribed)? 16 Undertaken any lab/blood tests, imaging tests viz. scans/mri in the last 5 years other than routine health check-up or preemployment check-up? 17 Undertaken any surgery or a surgery been advised and have surgery still pending? 18 Suffered from any other disease/illness/accident/injury other than common cold or viral fever? 19 Is any of the insured persons pregnant? If yes, please mention the expected date of delivery: 20 Any complaint of diabetes, hypertension or any complication during current or earlier pregnancy? C) Name and details of Illness/Medicine/Surgery/Diopt er grade (for questions answered in section A & B Exact diagnosis Diagnosis date Date of last consultation Treatment In/Outpatient and details of treatment given Doctor/Hospit al Name & Phone No: 1: 2: 3: 4: 5: 6: D) Name, address, qualification and contact details of the family doctor. If ANY: Qualification: Address: Postal Code: Mobile Number: Phone No: ID:

5 E) Does any person proposed to be insured smoke or consume Pan Masala/Alcohol. If, please indicate the name and quantity per week 1: 2: 3: 4: 5: 6: Alcohol Smoke Pan Masala Others F) In respect of any of the persons proposed to be insured: Has any application for life, health, hospital daily cash or critical illness insurance ever been declined, postponed, loaded or been made subject to any special conditions by any insurance company? Please enclose with this Proposal a copy of Medical Documents, ID Proof Copy(ies), Photographs and any additional information to the vessel and operation which you feel may be useful to the Company in assessing the risk Declaration I/We authorise Solarelle Insurance Private Limited to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. I/We declare that I/we have read and understood the duty of disclosure, non-disclosure and policy conditions contained herein and confirm that no information has been withheld which could affect the acceptance of this application. (No insurance cover is provided until the above proposal is accepted and details of cover are confirmed in writing by Solarelle Insurance Private Limited) Name of proposer: Date: Signature of proposer Company Stamp: Office use only Intermediary Premium / Rate: Special Condition: Broker / Agent / Sales Code:

First Name Middle Name Last Name. Telephone Mobile: Gender Male Female

First Name Middle Name Last Name. Telephone Mobile: Gender Male Female Please fill-up this form in CAPITAL LETTERS (Please leave a space after every word) and attach a passport sized photograph of Yourself and each proposed insured person and write the name of the person